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SAN JOAQUINI*UNTY ENVIRONMENTAL HEALTH OARTMENT SERVICE REQUEST Tyne of Business or Property FACILITY ID # BUSINESS NAME``,, i SERVICE REQUEST # bm'/': �? 5 t -h PHO # �T• 1 Ij i�►TE: -c , / '�O2M-O0 c:�- O ER O RATOR YJ I ////'''' �I DATE: r / CHECK if BILLING ADDRESS FAc1uTY NAME CITY r,/y{ ` STATE LP O7�5 SITE ADDRESS Amount Paid v O Payment Date Vl'"/c�-:�Z12WC)ode Payment Typetile( Invoice # Street Number Direction"51 C HOME or MM ADDRESS (If Different from Site Add res �01Street VCkMCA;Q1 �l i Number NSO - CITY ATE �) PRONE #1 EXT. APN # LAND USE APPLICATION # 0IgC• PHONE #2 ( ) ExT• BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS BUSINESS NAME``,, i i� �TMEV� MUE11 Ot +nJ •� Mqv a v �i 5 ;:u1i � M/1Y T 2 �EONI'�IENTAL N y F PHO # �T• 1 Ij HOME OX411AILING ADDRESS i�►TE: -c , / ASSIGNED TO: � `AX# EMPLOYEE #: DATE: r / Date Service Completed (If already completed): ) CITY r,/y{ ` STATE LP O7�5 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific E ONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business Identi don this form. I also certify that I have prepared this applic ion and t t the wor)t;A4 be pe Pedill be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, ST E and L WWS vl APPLICANT'S SIGNA DAT��(,,E��:(((�� PROPERTY / BUSINESS OWNER�is OP RA MANAGER ❑ OTHER AUTHORIZED AGENT ( ` If APPLICANT not the B NG PARTY proof of authorization to sign is require it Title AUTHORIZATION TO RELEASE I ORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize Ae release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: LA tTa COMMENTS: .� �A rl 12 V CA -6-1 CAK) 1 / � i� �TMEV� MUE11 Ot +nJ •� Mqv a v �i 5 ;:u1i � M/1Y T 2 �EONI'�IENTAL N ACCEPTED BY: l EMPLOYEE #: HEALTFI DEPAH fME i�►TE: -c , / ASSIGNED TO: � EMPLOYEE #: DATE: r / Date Service Completed (If already completed): SERVICE CODE: P / E: Z,�� Fee Amount: —" Amount Paid v O Payment Date cJ Payment Typetile( Invoice # Check # (S'?(od Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 1E 16 1LTH =S